Who is watching the bills?

Whose responsibility is it to monitor accurate procedure coding for a patient’s billing and account?

Can the patient reasonably be expected to audit and enforce correct coding? Is there a source of transparent codes/procedures (along with what is covered by an individual’s policy) that consumers can access?

Watchful Wonderer

Dear WatchfulWonderer,

The patient cannot reasonably be expected to audit and enforce correct coding. At best, the patient should be able to look at the bill and say, “Yes, I had an office visit on that date.” The patient would not be able to know or easily find out whether the doctor used the correct procedure code for the visit. There are, for example, different procedure codes for different lengths of time, or for an initial visit with a new patient instead of a visit with an established patient.

This is one of the central dynamics of the health insurance transaction. No one is “on the line” with the person facing them directly. The patient pays for health insurance; the health insurer negotiates with the doctor; the doctor bills the health insurer; the patient gets unintelligible notices in the mail about what was paid. Since the patient is not paying the doctor’s bill out of his own pocket, he or she has little or no motivation to proofread the bill or make sure he’s not getting extra tests or services that he doesn’t really need.

Consumer-driven, high deductible plans are meant to boost this motivation. There are also movements for “consumer engagement” and shared decision making. These may have some impact, but I’m skeptical that a seriously ill person will spend his time negotiating bills. He’s more likely to be focused on getting well.